Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.

Thursday, February 01, 2007

Influenced by....

If you recall, our dear ClinkShrink was recently ill with pneumonia and found herself the patient of a handsome young doc-in-the-box. She told us tales of her patienthood, and hid her doctor identity while the handsome young thing explained how the white blood count rises during an infection. Roy chimed in to say he also down-plays the doc thing when he's a patient: "I always heard that docs got worse care, not better. They don't get those nice explanations like you got, and the treating-doc tends to let the patient-doc drive the treatment plan bus more than is appropriate." I, on the other hand, can't stand relinquishing control, and could never lie low.

So, yesterday, I'm e-conversing with my wonderful friend, Linda, who is very sharp and very in tune to boundary issues. We got on the topic of something medical, and Linda e-mailed, "Countertransference, as you know, is a major issue in physicians treating physicians." She then steered me toward this sweet article by Jerome Groopman in the New Yorker, Medical Dispatches: What's The Trouble?

The article starts with a scenario starring Dr. Pat Croskerry, an ER doc who missed a diagnosis of cardiac disease in a slim, athletic, patient with no risk factors and a negative initial work-up. Dr. Croskerry assured the patient his chest pain wasn't cardiac, and oops, the patient bounced back later that day in the midst of an acute MI. Dr. Croskerry went on to study the cognitive factors which influence clinical decision making.

"But research shows that most physicians already have in mind two or three possible diagnoses within minutes of meeting a patient, and that they tend to develop their hunches from very incomplete information," Groopman writes. "The mistake that Croskerry made is called a “representativeness” error. Doctors make such errors when their thinking is overly influenced by what is typically true; they fail to consider possibilities that contradict their mental templates of a disease, and thus attribute symptoms to the wrong cause. "

Another type of error is deemed an 'availability' error: "Doctors can also make mistakes when their judgments about a patient are unconsciously influenced by the symptoms and illnesses of patients they have just seen." Ah, ClinkShrink didn't really have pneumonia, her doc-in-a-box missed the diagnosis of Multiple Personality Disorder because one of those clinky alters was coughing and the four prior patients had all had pneumonia! (Just kidding, there's only one ClinkShrink.)

Finally, Dr. Groopman goes on to talk about how doctors' feelings can get in the way of making the right diagnosis. He cites an example from his own practice, one where he missed finding an abscess in his favorite patient on the ward, a man he enjoyed discussing literature and running with.

"I was furious with myself. Because I liked Brad, I hadn’t wanted to add to his discomfort and had cut the examination short. Perhaps I hoped unconsciously that the cause of his fever was trivial and that I would not find evidence of an infection on his body. This tendency to make decisions based on what we wish were true is what Croskerry calls an “affective error.” Groopman goes on to write, "When people are confronted with uncertainty—the situation of every doctor attempting to diagnose a patient—they are susceptible to unconscious emotions and personal biases, and are more likely to make cognitive errors."

I suppose I wanted there to be a story about a doctor missing the diagnosis on another doctor, it is, afterall, what I was thinking about. This will be good enough, though. Our relationships with our patients-- perhaps even more so in psychiatry-- are complicated. Our feelings, our hopes, our own issues-- maybe they get in the way, certainly they add to the mix.

Post Script: Check out The Last Psychiatrist, post of 1/31/07: When the Patient's Parent is a Psychiatrist and a Patient and You Just Want to Go To Bed.

The other has to do with the fact that it's tough on me when bad things happen to strangers I happen to be taking care of. I had to do a stat c-section once on a friend as a resident (mom and baby are healthy now), and that kind of sucked. I can't imagine how hard it would be if something terrible happened to someone who was my friend who I was their doctor.

On a related note, if you haven't read the book Blink yet it's worth taking a look. It's about the role of intuitive or unconscious perception in human behavior. The book talks a little about how this plays out in the medical realm (ER docs admitting folks for MI workups) but also in other areas. The bottom line was that decisions based on intuition can sometimes be wierdly accurate and that accuracy slips when the person is asked to rationalize or explain the decision-making process.

The relevance for psychiatry is that maybe there's reason to believe that after a certain number of years of clinical experience it would be possible to accurately diagnosis someone quickly and will relatively little clinical information. I don't think anyone will ever test that theory, but it's interesting to think about.

I want to talk about it! but tomorrow. I am going to pick one example out of several, and I will try really hard to be brief. But I have to catch a train at like 5:45am since I have no car and it's supposed to snow....so I am not staying up tonight, but wanted to let you know that I want to talk about it! I liked it, as usual. :) I bought a good book that I may write about someday soon....something about uncluttering your mind. I also bought a journal. In lieu of my lack of blogging now, I am going to write - and I think I will end up writing more than I could ever say on the blog, anyhow. :) Good thing it has lots of pages *wink*

Will write a response to this tomorrow night though maybe. Very interesting and good topic, and I think it explains why I was not diagnosed with cluster headaches right away, even though I was seeing a world-reknowned specialist.

I am in the midst of reading "In Session" by Deborah Lott which discusses the relationships that women have with their therapists. It's quite interesting, and a good read at that. It attempts to address the patient's perceptions of what her therapist is thinking of, and the imbalance in relational power between therapist and client/patient.

On another note, could you please post the link to the post from Lost Psychiatrist's blog.

That's very interesting and I do believe that medical professionals of all ilk can be subject to many biases/predispositions etc... This comes as no surprise to me at all! I mean, they're only human! That's why I come well prepared with actual research to my appointments! Yes, I may be a physicians worst nightmare (or best patient?) depending on who they are.

I had to extricate myself from, in hindsight, a rather co-dependent relationhip with my last Family Practitioner. We were almost like an old married couple. Granted, he bestowed three honourary PhD.s/MDs on me in the process because I argued SO hard with him about my diagnoses and meds and problems (and usually turned out right.)

But he was very stubborn and dismissive and if I didn't persevere and supply him with hard evidence and fact--or even anecdotal evidence I was so desperate at times, I wouldn't have gotten the help that I needed.

So in a lot of ways, "the patient drove the bus" in that relationship but it destroyed me and I had to finally see someone else. I got so tired of advocating for myself that I just couldn't do it anymore.

We fought so much and then he'd turn around and play all of these really weird mind games. He was so full of drama. Truly unhealthy.

Oh, and note to gerbil: I actually posted about BDSM and tied it into Temple Grandin's work with calming effects of deep touch pressure...but I'm a freak.

Notice from Dinah:Dear readers, We are three undisguished or thinly disguised psychiatrists...we're having a blast with our blog, glad to stir up some controversy &opinions on the provocative issues we deal with. Please, though, No Obscenities. We're interested in thought-provoking discussion. It loses its charm as it degenerates.Thank you,The Management

Wow! I have a personal crisis for a few days and come back to what feels like the Twilight Zone here. Some of the comments from the last few posts seem out of whack. Not the normal types of comments you guys get. They're very entertaining, but wow! haha! Ok...back to my family crisis.

Note to self...keep checking these comments to see if they get even more entertaining! :-P

In 2003, my neurologist at the headache center moved back to Singapore, which was really devastating to me. When I first saw him back in 2001, he said I either had one of two types of headaches: hemicrania continua or new daily persistent headache. He'd said that hemicrania continua would be the more fortunate of the two since it is cured about 99.9% of the time by taking indomethacin. I did a trial of indo, and the headache didn't go, so NDPH it was.

However, a curve ball happened in the spring of 2003 when I had my skating accident, and after that, I started having these shorter lasting, explosive headaches right above my right eye. In the beginning, they last only like 2 minutes, and they'd come up to 20 times a day. They weren't even that frequent over the summer (after the accident...), but by the time the fall came, they were in that full blown pattern. Over that fall, they morphed from what seemed like either chronic paroxysmal hemicrania or idiopathic stabbing headache into a more cluster-like pattern. By October or so, I was getting them every night at 5pm, 7pm, 9pm, 11pm, 2am and 4am....and they lasted 45minutes to an hour. Having worked in the headache center over that summer, I knew what clusters were, but I didn't even fathom that I was having them.

Then I found the world of headaches on the internet. Can't believe it took me until 2003 to discover headache sufferers on the internet...never even looked much for support groups prior to that. I found this chat room sort of connected to clusterheadaches.com, but I found the chat room before the site. A very good friend there, Billy, stood up for me while others shot me down as the dumb migraineur. He helped me describe it better - when people would ask me about my headaches, I'd just describe every characteristic of what I was feeling and lump it all together, so of course it didn't sound like it fit anything. But he helped me learn to separate out the symptoms and characteristics - when someone asks how long my headaches last, there is one type that never goes away, but there is a different type entirely that comes, lasts about an hour, and goes as quickly as it comes. I don't get pain free - but that headache goes away, leaving me with my constant.

So long story short (and I'm serious) - November 18, 2003, I went to a new neuro who had been in the field for yearssss longer than my former neuro who moved to Singapore. I had been looking forward to the appt because I had been sleeping 1-3 hours a night, thanks to the clusters. I was afraid to go to sleep because it was better to be awake when they started, rather than to wake up when they were in full blast. I described these to my neuro, and he waved his hand and said, "There is no point in treating or aborting those headaches." I asked him if he still thought my diagnosis was New Daily Persistent Headache, and he said to me, "Yes...what else would it be?" I said that I didn't know, but it didn't seem to fit what I'd read about NDPH anymore. He blew it off. After I left, I cried for 3 days straight - had to go back to Penn State with no ways to get through those cluster attacks...

He basically didn't even listen to my discussion of the clusters because he blew it off as idiopathic stabbing headache (ice pick headaches). Also, I had been a constant patient at the center for 2 years at that point, so I guess he was thinking that it was unlikely that I'd developed a new headache type. Especially not between one neuro leaving and me starting with a new one. But he just dismissed it so suddenly.

I actually ended up in the ER the next day with a 4 hour cluster headache attack - but I was back up at Penn State by that time. 4 hours is the longest I've had one last, and it's happened a few times. By that December, I was admitted to the hospital back in Philly for how severe my headaches were. I was really a wreck at that point, having not had a good night's sleep in a few months. The first night, my neuro came up for his initial exam. But what had changed was that I had really become educated about clusters at that point, and I was darn sure he was going to get it this time. So I made sure that I didn't mix my 2 headache types together when talking about them in any way. I made a point of really describing the clusters as the separate entity that they are.

As soon as I finished telling him what I had been going through, he asked me some questions. (Oh I had also called my dad's best friend the night before - he is a lawyer and he had been a chronic clusterhead for 9 straight years until 1980 when they mysteriously went away. When I told him what I was going through, he said he truly had forgotten what they had been like, but as I was describing what was happening, he was actually feeling that pain again. He was certain they were clusters.) My neuro then immediately asked the nurse to make sure that I had a nonrebreather mask available at the bedside and the ability to go up to 15LPM on the O2. He had the nurse tell me how to use the oxygen. I had known about O2 for clusters, but had had no access to it prior to that night - and had been dying to try it for the attacks.

I tried oxygen for the first time that night and cried. My headache aborted in 15 minutes. And I finally slept.

Overlooking diagnosis can really have a HUGE effect on somebody's life. And I know I wasn't good at explaining them as 2 separate headaches at that time, but when he first blew the clusters off, I really felt like my life had ended. I didn't know how I could keep going indefinitely and have clusters basically every 2 hours all night long. This lack of sleep and severe pain had exacerbated my chronic migraine, which landed me in the hospital, where I was finally diagnosed. I was never so happy to receive a diagnosis for anything in my entire life.

Sorry for the length, but that story means more to me than any other medical thing I have gone through in my entire life. It pays to listen....it would have taken maybe 5 minutes to really listen to me and help me figure it out. But at least I didn't have to go 10-20 years misdiagnosed like some CH'ers I know.

I have a noob request. I thought I sort of understood the basic concept of transference and countertransference, but now reading the comments, I think I've probably got it wrong. Could I ask one of you folks to clarify the difference, please? Is there a PoV issue?

And a second request, if I may. When I think counter/transference, I think Freud. But I thought "real" psych types had pretty much decided Freud's work wasn't actually that useful? Could you explain a bit where you folks find Freud (or better, Lacan!) useful, and where not?

Dinah, I'll try to give you the short lesson on how to embed links in the comments, because it's really easy. I cannot type the arrow version of a bracket (html tags that would replace the parenthesis here if I wanted to (b) bold something or (i) italicize something) - if I type the correct little arrow symbol, then this will say I have made an html error. So for purposes of this explanation, the little arrow is going to be a parenthesis.

(a href="http://www.exactlinkhere.com/")Title of Link Displayed(/a)

Got that? Replace the parentheses with their corresponding little arrow symbol facing the right directions...I don't know what that thing is really supposed to be called! ;)

I was about 23. This happened about 14 years ago, either after my first or second suicide attempt.

The insurance I had, contracted with a "behavioral health" group for therapy, so there I was sent.

I remember a large rectangular office. He, red headed and bearded, sat on one end behind a desk, and I sat on the other end.

The only place to sit was a seat that looked like a park bench, so that's where I sat.

I don't remember anything about our coversation, really, except at one point he stopped.

He said I was being *seductive*.

I was simultaneously confused, shocked and humiliated.

Apparently it was the way I was sitting.

Since I am quite short (5'1), my feet tend to dangle sometimes and it starts to hurt, so I tuck my feet up. In this instance I tucked my legs and feet up under me and covered them with my dress. I was wearing my favorite dress. I had come from where I worked at a financial institution so I was dressed up.

I was very upset. No one had EVER accused me of this and I was so happy and in love with my then husband. I didn't understand but I knew that he was the professional and if he said it then it had to be true or have some truth.

I told myself that it was ME. I was sick and I needed to suck it up and try to find the truth in what he said. I needed to go back, and go back I did.

I don't remember the things he said to me beyond what I have already said. I remember a very bad feeling. BAD.

You know that old show "Family Feud"? Well, when you gave a wrong answer you got a BZZZZZZZZZZZT and a big red X would appear on the TV screen. That is how I felt.

BZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZThis FEELS WRONG!!

I remember leaving mid session once or twice but on our last session I felt like I was in danger. I fell the buzzing and the wrongness. I left. He was right behind me as I walked through the waiting room toward my husband for us to leave.

In essence I FLED. I never went back.

AFTERMATH: To this day I worry about what I am wearing, how I'm sitting and how I might look to whatever mental health professional I am seeing. I don't wear makeup. With new shrink I only wear black and make sure I have a high collar. I hate it when I am looked at.

I don't know what this means. But I know the red devil hurt me and I know that he deserves his name.

From the transference link, it seems like the difference between transference and countertransference comes more through point of view or position in the relationship than being a set thing? Or is the countertransference a reaction to the transference itself? (or separate and maybe preceding?)

Thanks, Carrie, for trying to teach Dinah how to do links. Perhaps you'll have better luck than I.

As to the transference issue, it is a term typically reserved for the feelings that the therapied develops towards the therapist, while countertransference refers to the feelings that the therapist develops towards the therapied (probably not a real word).

However, as these terms have crossed over from the analyst's world to the real world, transference has come to mean any feelings one develops towards another person, which are based on feelings one has towards some other individual, usually due to some shared characteristics.

And yes, countertransference, in this larger context, would refer to the feelings one develops in response to perceived transferential interactions from others. So, there is a point of view component. (One man's transference is another's countertransference?)

And Lily, I'm sorry to tell you that doctors *do* think in terms of "template 317 with modifications to lines a, b, and g". It's called case-based learning, and is really just a form of categorization.

If you think of each disease or illness as a particular animal, when someone brings an animal for you to "diagnose", you start thinking like, "hmm, it has 4 legs, and fur, large canine teeth, is about yea high, and makes a specific sound. Still not sure, so I'll ask some questions, to help me rule out a, b, or g, until I am eventually left with a short list, ranked in decreasing order of likelihood. This way of thinking is highly dependent on both one's "book knowledge" of disease characteristics (that's what medical school starts you off with), and one's experience with past similar cases (residency and beyond). If you see enough of these different animals, you begin to recognize them quickly, in the way that Clink refers to in her comment above about the book, Blink (hmm... that's the link to ClinkShrink's Blink).

Re: Gerbil's BDSM link, we talk about this briefly in an upcoming podcast.

So I just read this whole post, and this "representativeness error" that Groopman mentions describes an error that I see a lot in my medical colleagues. Example: tearful pt goes to ER c/o SOB and CP, is on Paxil. Doc attributes SOB to anxiety and depression after a quick exam, negative ECG, and neg CXR. Gets a psych consult. Psychiatrist suggests a spiral chest CT to r/o PE (no, not that PE... pulmonary embolism). Reluctant doc gets scan, finds PE.

Most ER docs who get a pt with acute onset chest pain and shortness of breath will think pulmonary embolism. Many have this bias that a psychiatric illness is responsible for any kind of symptom that *could* be part of that illness, and just stop looking after a minimal rule-out of other things. That is why many pts will not inform the ER doc about the psych med they are on, so that this bias does not creep in.

Believe it or not, I do know how to tap dance - but just a very little bit! I learned when I was accompanying "Crazy for You" in high school. Not sure if a duck could learn it, but hey - if you put character shoes on him (?), he'll be tappin away! I'm sitting here laughing thinking about me teaching the duck from the Aflac commercials how to tap dance... Then the duck slips and falls off the stage and yells "AAAAAAAAaaaaaaflaaaaaac!!" Hmm...maybe I should talk to their advertising director! lol...

Roy,

My friend who is a psychiatrist was once telling me something similar about the ER at our hospital. She was doing her ER psych rotation this one time, and I can't remember why she said this to me, but I think maybe we were trying to get together for lunch or something and she was really busy. She said something like, "If you end up in the ER...just name the meds you're taking - if one of them is a psych drug, then they'll automatically consult me and I'll get to see you!" LOL... She's right though... If you just name ANY psych drug - they think you've just had an exacerbation of a psychiatric illness...especially if your symptoms aren't well-defined. I have to spend a lot of time clarifying things when I go to the ER - especially with respect to the headaches.

The last time I went to the ER was for my shoulder injury. That day, I had taken ultracet, aleve, had gone through 2 lidoderm patches, tried ice, heat, rest, a hot shower - and I was still in excruciating pain to the point of having to catch my breath at times because of the shoulder spasms. But I'm a chronic pain patient - so I was so anxious about going to the ER that I was very reluctant to have my dad even take me. Then, when I saw the attending, he said that my xray was fine and "maybe it is just one other aspect of your RA that you're just going to have to learn to deal with." Excuse me? I'm a nurse and I can't even lift my arm away from my side. Just because I'm on methotrexate for questionable RA means that my shoulder that is very obviously screwed up is just a symptom of my RA? Or that I'm exaggerating the pain because I have chronic pain? I couldn't even sleep the pain was so severe. This is not the kind of pain that you just "get by" with. But the stereotypes were set.

Even when I went in with the allergic reaction to chlor-kon, I think the resident kind of thought that perhaps this was more anxiety attack than allergic reaction because the hives had gone away by the time he saw me...but I still had some airway swelling and a lot of shortness of breath. The kicker was when the next shift resident came in to discharge me. My heart rate every time I sat up was jumping to the 120s and my blood pressure was like 150s/100, and I was clearly concerned about this as I had come off of verapamil within the last month or so. I have a history of SVT and hypertension. The resident said it was just pain and they weren't concerned about it. I'm 26 and thin - I shouldn't have vital signs that look like that and have it just be "okay" - I know I have familial hypertension, but still. I've also had clots in my arm and my grandfather died of a PE. I had been asking if there was any way for me to get a dose of my usual medications and he said that the only way I could get them was if they gave them IV and kept me there for headaches, and I thought that was ridiculous, but I had missed doses for about 12 hours at that point, and I ended up having a full out cluster attack. I left during it, in tears....from the pain, the stress, leaving when I didn't feel right and having not slept for about 36 hours by that point. The doc was trying to discharge me, and my mom was saying "thank you" on my behalf because I didn't feel like showing my gratitude when I felt I was being dismissed. (I have high standards for medical professionals - and yes, I hold myself to those same high standards as a nurse...)

The next day, I went to my family doctor who I'd been seeing for years. His twin daughters used to take piano lessons from the same teacher I took lessons from before going to college. He had even video taped my playing at a recital once when my parents couldn't make it. Good guy. He had a PA student with him that day, and I was trying to say that I needed someone to help me figure out my heart rate and blood pressure stuff and just the overall fatigue, severe chronic pain and the rest of it. He was the first person who originally tried to help me with the headaches. He looked at me and sighed. Then he turned to the PA student and said, "Carrie has been through a lot in the past few years. It's hard - it's been a long road." And here came the tears again. (It should be evident that I cry over everything by now!) To appease me, he ordered a holter monitor and ordered atenolol for me to take 25mg/day. He had always said that the two treatments for headache he thought I should do were either a beta blocker to lower my pressure and consequently help the headaches or an antidepressant because he truly believed that all the stress in my life was what was causing the headaches. My blood pressure and heart rate were normal at that appt - which just made me feel like I made it all up and was making a big deal over nothing from the ER the day before. I felt he was just appeasing me. I was rather depressed as the nurse was putting on the holter monitor and asking me if I knew how to work it - which I did because I had to have one once before. I didn't even fill the atenolol prescription because I thought he just did it to do something, but I didn't think he really believed I needed it - I think he may have even said something along the lines of "25mg of atenolol can't hurt anyway." He's a nice guy - I know he tried really hard to help me... Well - when they read the report from the holter - I had had several episodes of tachycardia where I had pressed the button for feeling palpitations and other episodes where I didn't push the button - some of the episodes had even woken me up from sleep. So I felt at least slightly more validated in my concerns and filled the atenolol. The office wanted to be sure I was taking it and wanted me to come back in a month for a checkup. But I also then started going to a phenomenal internal medicine doctor who agreed to help manage my care instead of just shooting me off to a new specialist with each new symptom. I haven't seen her in about a year, but I really REALLY like her. She goes above and beyond.

Sorry - I know you asked for concise-ness (is that a word?) but those are the incidents that I remember a doc just sort of not looking into a diagnosis (or looking into it begrudgingly just to make me feel better) just because I had some other pre-existing condition - be it psych related or pain related. At least it is relevant! And writing is helping me focus on other things today - if you haven't read my blog post, my family lost one of our closest friends to complications from lung cancer this morning. It's been a rough day, so I needed the distraction.

I was just watching Dr. G Medical Examiner and one of the stories was about a Vietnam vet who had PTSD and died suddenly in bed. Turns out that he had chest pains a week before he died, but didn't see a doctor. All the other times he had chest pains, his doctors kept saying it wasn't a heart problem, but was just his PTSD and a panic attack. They wouldn't even run tests on his heart. In the end, Dr. G found out that he actually did have a massive heart attack the week before he died and the heart muscle was so damaged that it basically exploded filling the heart sac with blood. Ouch!!! Her final hypothesis as to why he didn't go to a doctor this time was because all the previous times he had gone, he was told the chest pains were just panic attacks. He just dismissed this pain as another panic attack with no reason to see a doctor and go through the whole "it's a panic attack" ordeal again. It's sad.

and the resulting failure for accurate psychiatric diagnosis can be due to deliberate self-presentation skills on the part of the afflicted person. Perhaps in hope that some things can be resolved without complete openness; perhaps by way of a person's nature.

I would like to be more specific, but haven't the patience to list examples. I am sure that professionals here have their own patient experiences tucked away.

In Jane B., (pardon my over-generalizations), if weight wasn't introduced as a concern by the patient, how many physicians would attribute it to stress/being overworked? How many have experienced a comparative representation of a black/Hispanic single mother with extreme eating issues? And, aren't those cultures more accepting of curvaceous female physiques? Anthropologically, would an eating disorder even be in her view-finder as a coping mechanism? If the health practitioner asks Jane A. a question about her eating, and she excuses herself (as some/many eating disordered individuals do) how much more likely would said practitioner be to press the concern that if it were Jane B. saying "I just have a fast metabolism, and run after my 3 year old all day. Besides, I don't worry about my weight. I eat plenty."? Comparison material plays a large role.